Provider Demographics
NPI:1710496989
Name:KIM, HO MIKE (RPH)
Entity Type:Individual
Prefix:
First Name:HO
Middle Name:MIKE
Last Name:KIM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11774 S TWIN PINES CT
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-4519
Mailing Address - Country:US
Mailing Address - Phone:801-450-1370
Mailing Address - Fax:
Practice Address - Street 1:11100 S AUTO MALL DR
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-4171
Practice Address - Country:US
Practice Address - Phone:801-790-0002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-20
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT153175-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist